Draw up a typed contract that explicitly describes the agreement between you the student, the supervisor,
and the site, including:
student’s name, address, and telephone number
the name, address and telephone number of the site
the clinical supervisor’s name and credentials
the contact person for the site, if different from the supervisor
the time commitment per week/per semester by the
the supervision commitment by the supervisor
Offsite Fieldwork Contract
Home Phone:
Work Phone:
Phone Number:
Contact Person:
I, Student's Name: , agree to provide approximately
hours of counseling-related
during the services as a Master's level fieldwork student at the Site's Name:
four-month period between MM/DD/YYY: and MM/DD/YYY: .
During this time, I agree to become familiar with the policies and procedures of the Site's
Name: . I will observe therapy, do co- therapy, and do individual, group, and family
therapy on my own as directed by my supervisor, Supervisor's Name: . I also agree to be
available to help with any other therapy-related or educationally relevant experiences that would be helpful
within the constraints of the 300 hours. In all of my work, I will observe the established policies and procedures of
the Site's Name: .
. I will meet the responsibilities of a clinical supervisor as outlined in the
“Clinical Supervisor Responsibilities” form. This includes meeting one hour face-to-face per week, regardless
of hours Student's Name:
has spent with clients. To the degree that I am able, I will try to structure
time so that he will have a minimum of
. I will complete periodic evaluations of Student's Name:Student's Name: and,
after discussing it with Student's Name: , will give him the original to be uploaded to Blackboard.
, as the site director, of Site's Name:
agree to give
to release confidential information to Supervisor's Name:
I, Site Director:
permission to Student's Name:
the off-site
It is understood that the student has completed all necessary prerequisi
tes for gaining supervised experience
through the counseling internship. The MA in Addiction Counseling program allows students to choose intensive
or online options for the helping techniques, group counseling, and diagnosis and treatment planning courses. We
(student and supervisor) have discussed the student’s choice of course format as part of the internship
arrangement and agree to proceed with the internship according to the terms described above.
Supervisor Signature Date Student Signature Date
Site Director Signature Date
Addiction Counseling
Student's Name:
hours of face- to-face contact with
clients. I understand that this contact can include co-therapy, individual, group, and/or family therapy done by
I, Supervisor's Name: , agree to supervise Student's Name: approximately 1
hour of individual supervision per week during the period between MM/DD/YY: and